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Non-Whipple Operations in the Management of Benign ANTICANCER RESEARCH 37 : 1443-1452 (2017) doi:10.21873/anticanres.11468 Non-Whipple Operations in the Management of Benign, Premalignant and Early Cancerous Duodenal Lesions ALEXANDROS PAPALAMPROS 1* , DEMETRIOS MORIS 1,2* , ATHANASIOS PETROU 3, NIKOLAOS DIMITROKALLIS 1, IOANNIS KARAVOKYROS 1, DIMITRIOS SCHIZAS 1, IOANNA DELLADETSIMA 4, THEODORE N. PAPPAS 5 and EVANGELOS FELEKOURAS 1 1First Department of Surgery, Laikon General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece; 2Department of Surgery, The Ohio State University Comprehensive Cancer Center, The Ohio State University, Columbus, OH, U.S.A.; 3Nicosia Surgical Department, Division of Hepatobiliary Pancreatic Surgery, Nicosia General Hospital, Nicosia, Cyprus; 4Department of Pathology, Medical School, National and Kapodistrian University of Athens, Athens, Greece; 5Department of Surgery, Duke University, Durham, NC, U.S.A. Abstract. Aim: We reviewed our 20-year experience with Early postoperative complications were noted in 13 cases non-Whipple operations (pancreas-preserving duodenectomy (54.17%). There were no postoperative (90-day) deaths and transduodenal ampullectomy) for the treatment of observed in this series and there were no recurrences during benign, premalignant or early-stage malignant duodenal follow-up for the patients operated on with neoplastic lesions. Patients and Methods: Twenty-four patients who lesions. Conclusion: For carefully selected patients, underwent non-Whipple operations between January 1996 transduodenal ampullectomy and pancreas-preserving and December 2015 were identified from an institutional duodenectomy may be used in place of the Whipple database and retrospectively analyzed. Results: Between operation for benign and occasionally early-stage malignant 1996 and 2015, 10 patients underwent pancreas-preserving (Tis and T1) duodenal and ampullary disease. duodenectomy and 14 patients underwent transduodenal ampullectomy. The mean follow-up was 25.8 months Duodenal tumors are rare (1, 2) and surgical resection of the (range=6-54 months) and no patient was lost to follow-up. duodenum is challenging due to its proximity to and Eighteen patients had preoperative diagnosis of duodenal common blood supply with the pancreas (3-5). Some lesions adenomatosis, three patients had preoperative diagnosis of in the duodenum or at the ampulla may be resected duodenal adenocarcinoma, one had a bleeding polyp and endoscopically but this approach is limited to small (less two had localized inflammation. Average operative time was than 2 cm) superficial lesions (6). For these reasons 145 min (range=127-168 min) for transduodenal pancreaticoduodenectomy (PD) is the most commonly used ampullectomy and 183 min (range=173-200 min) for operation for both benign and malignant duodenal lesions pancreas-preserving duodenectomy (p<0.05). The estimated (7). Unfortunately, PD is often associated with postoperative blood loss for transduodenal ampullectomy was 85 vs. complications, since postoperative pancreatic fistula (POPF) 125 ml for pancreas-preserving duodenectomy (p<0.05). is commonly encountered in these patients due to their soft pancreatic parenchyma and small pancreatic duct (8). In addition, pancreatic head resections are often associated with significant attenuation in pancreatic endocrine and exocrine *These Authors contributed equally to this study. function (9). Transduodenal ampullectomy and pancreas- preserving duodenectomy are operations that have been used Correspondence to: Demetrios Moris, MD, Ph.D., Department of for resecting duodenal lesions and have been reported to Surgery, The Ohio State University Comprehensive Cancer Center, have a lower morbidity and mortality than PD (10). The Ohio State University, Columbus, OH 43210, U.S.A. Tel: +1 Transduodenal ampullectomy (TDA) is a relatively old 2164442574, Fax: +1 2164454658, email: [email protected] operation mainly offered to a very narrow group of patients Key Words: Pancreas-preserving duodenectomy, surgical ampullectomy, with ampullary adenoma who have lesions that are large ampullary lesions, pancreatoduodenectomy. enough to exclude them from having endoscopic resections 1443 ANTICANCER RESEARCH 37 : 1443-1452 (2017) but not so large to warrant PD (10). Emerging data indicate its potential role in resection of early ampullary tumors (11, 12) since it is a less invasive and simple technique, that could potentially provide equivalent clinical outcomes to PD for early ampullary malignancies. The success of TDA is mainly based on the absence of nodal metastasis and the achievement of R0 resection (13, 14). In 1995 Chung et al. (15) published the first series of pancreas-preserving duodenectomies (PPDs) for premalignant duodenal lesions (15). To date, about 270 cases of PPD (partial and total) have been described, with low mortality and variable morbidity rates (15-56). Unfortunately, no large series of PPDs have been published (largest series fewer than 30 cases), but data available suggest that this technique is feasible, safe and may be associated with shorter operative time and reduced blood loss compared to PD (15-56). In addition, PPD enables postoperative endoscopic follow-up of Figure 1. Algorithm of decision-making on duodenal lesions. TDA: the whole gastrointestinal tract, including the neo-duodenum, Transduodenal ampullectomy, PD: partial duodenectomy, PPD: for patients with familial adenomatous polyposis (FAP), pancreas-preserving duodenectomy, Tis: tumor in situ. which account of the majority of patients currently treated with PPD (15-56). We present a series of non-PD operations (PPD and TDA) scan findings and clinical course. Early postoperative hemorrhage for the treatment of benign, premalignant, and early and delayed gastric emptying (DGE) were defined according to the malignant duodenal lesions. The technical aspects, and International Study Group of Pancreatic Surgery (58-60). outcome of these operations are reviewed. We also review the literature concerning the outcome after non-Whipple Pre- and postoperative management of patients undergoing PPD and TDA. resections of the duodenum. All patients with benign or early-stage duodenal cancer who were being considered for PPD and TDA were routinely investigated preoperatively with endoscopic ultrasound and biopsies Materials and Methods (61) and magnetic resonance cholangiopancreaticography (47). Any case of provisionally benign disease that could not be treated by Twenty-four patients who underwent PPD and TDA between endoscopic means (median of two endoscopic attempts) was January 1996 and December 2015 at Laikon General Hospital, deemed appropriate for PPD or TDA. In most cases where there was Greece and Nicosia General Hospital, Cyprus, were identified from an intraoperative suspicion of an invasive disease after frozen their institutional computer-based databases and retrospectively section, a PD was performed. Exceptions to this included three analyzed. Two senior surgeons performed all operations. Standard cases in which patients had poor performance status and could not demographic and clinicopathological data were collected, including undergo PD. They were offered TDA. In addition, patients with gender, age, presenting symptoms, preoperative diagnosis/indication poor performance status with pT1 or pTis disease were offered TDA for PPD/TDA, type of operation, postoperative histological instead of PD. Figure 1 illustrates our decision-making algorithm diagnosis, postoperative mortality and morbidity, and follow-up. for patients with duodenal lesions. Intraoperative data included operative time. Operative notes Postoperatively, standardized management included clinical provided information on treatment-related variables, such as evaluation twice daily and daily analyses of blood and drain-fluid indication for resection and specific type of resection. Clavien- samples as described earlier (62-66). Postoperative mortality was Dindo classification system (57) was used to record the defined as death occurring within 90 days after surgery or during perioperative complications with a major complication classified as hospital stay. grade 3 or more. For patients with two or more complications, the most severe was taken into account. The length of hospital stay for Operative techniques. TDA: After an extended right subcostal each patient was recorded. incision, the peritoneal cavity is carefully explored to exclude systematic spread. The second portion of the duodenum is palpated Definition of POPF and other short term outcomes. POPF was in a bimanual fashion to identify the lesion and the ampulla of Vater. defined as drain output on or after postoperative day 3 with amylase Two-stay sutures (Vicryl 3-0) are placed and a 3-4 cm longitudinal content at least three times that of the serum amylase level (58). incision is made along to the lateral wall of the second portion of the Fluid collection was defined as that identified through computerized duodenum opposite the ampullary tumor. In order to achieve better tomographic scan or ultrasound greater than 5 cm in diameter, with retraction of the lesion, a figure-of-eight suture [polydioxanone or without clinical relevance. Acute pancreatitis was defined as a (PDS) 4-0] is placed through the mass. A submucosal injection of threefold increase of normal serum amylase or lipase values after dilute epinephrine (1:10,000) beneath the mass is performed to the third postoperative day, confirmed by computed tomographic prevent bleeding during
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